Management Of Convulsive Status Epilepticus Research Articles

Seizure control via pH manipulation: a phase II double-blind randomised controlled trial of inhaled carbogen as adjunctive treatment of paediatric convulsive status epilepticus (Carbogen for Status Epilepticus in Children Trial (CRESCENT))

BackgroundPaediatric convulsive status epilepticus is the most common neurological emergency presenting to emergency departments. Risks of resultant neurological morbidity and mortality increase with seizure duration. If the seizure fails to stop within defined time-windows, standard care follows an algorithm of stepwise escalation to more intensive treatments, ultimately resorting to induction of general anaesthesia and ventilation. Additionally, ventilatory support may also be required to treat respiratory depression, a common unwanted effect of treatment. There is strong pre-clinical evidence that pH (acid–base balance) is an important determinant of seizure commencement and cessation, with seizures tending to start under alkaline conditions and terminate under acidic conditions. These mechanisms may be particularly important in febrile status epilepticus: prolonged fever-related seizures which predominantly affect very young children. This trial will assess whether imposition of mild respiratory acidosis by manipulation of inhaled medical gas improves response rates to first-line medical treatment.MethodsA double-blind, placebo-controlled trial of pH manipulation as an adjunct to standard medical treatment of convulsive status epilepticus in children. The control arm receives standard medical management whilst inhaling 100% oxygen; the active arm receives standard medical management whilst inhaling a commercially available mixture of 95% oxygen, 5% carbon dioxide known as ‘carbogen’.Due to the urgent need to treat the seizure, deferred consent is used.The primary outcome is success of first-line treatment in seizure cessation. Planned subgroup analyses will be undertaken for febrile and non-febrile seizures. Secondary outcomes include rates of induction of general anaesthesia, admission to intensive care, adverse events, and 30-day mortality.DiscussionIf safe and effective 95% oxygen, 5% carbon dioxide may be an important adjunct in the management of convulsive status epilepticus with potential for pre-hospital use by paramedics, families, and school staff.Trial registrationEudraCT: 2021-005367-49. CTA: 17136/0300/001. ISRCTN: 52731862. Registered on July 2022.

Efficacy of intravenous clonazepam for paediatric convulsive status epilepticus.

To compare the efficacy of intravenous clonazepam (CLZ) for the initial management of convulsive status epilepticus (CSE) in children as a function of the first-line in-hospital dose used. This monocentric retrospective study included children who received a first dose of CLZ for CSE at Montpellier University Hospital, France, between January 2016 and June 2019. Data from medical records (clinical, treatment, course) were collected and compared as a function of the first CLZ dose used. Among the 310 children treated for CSE, 105 received at least one CLZ dose (median age 3 years; quartile 1-quartile 3 [Q1-Q3] = 1 years 2 months-6 years 6 months). Among these 105 patients, 24 (22%) received a dose less than 0.03 mg/kg (low dose) and 69 (65%) received a dose of at least 0.03 mg/kg (high dose). Seizure cessation rate was not different between the low- and high-dose groups (62.5% vs 76%; odds ratio 0.53, 95% confidence interval [CI] 0.19-1.44, p = 0.29). The administration of a second dose of CLZ was more frequent in the low- than the high-dose group (37.5% vs 16%; odds ratio 3.2, 95% CI 1.1-9.1, p = 0.04). Our study did not find any difference in seizure termination rate as a function of CLZ dose in children with CSE. However, a second CLZ dose was more frequently needed in the group receiving low (less than 0.03 mg/kg) CLZ.

Management strategies for refractory status epilepticus

Refractory status epilepticus (RSE) is defined as the persistence of either clinical or electrographic seizures despite the administration of appropriate doses of an initial benzodiazepine and suitable second-line antiepileptic drugs (AEDs). The Neurocritical Care Society and the American Epilepsy Society have proposed a treatment paradigm for the management of convulsive status epilepticus (CSE). The third-line therapy in refractory CSE may involve general anesthesia using intravenous midazolam, propofol, or other agents, while recent evidence supports the use of ketamine to manage RSE in both adults and children. However, although these treatment strategies are frequently employed in nonconvulsive status epilepticus (NCSE), the efficacy of AEDs and anesthetics in NCSE has not been thoroughly investigated. Recent evidence has demonstrated the safety and efficacy of newer AEDs, including levetiracetam and lacosamide, in the treatment of status epilepticus (SE) and RSE, which also encompasses NCSE. Use of multiple combinations of various intravenous AEDs can also be considered in NCSE before the administration of general anesthesia. In addition, AEDs alone exhibit limited effectiveness in managing SE for new-onset RSE (NORSE) and its subset, febrile infection-related epilepsy syndrome. Therefore, in cases of refractory status, it is imperative to explore treatment options beyond AEDs, including immunotherapy and the incorporation of a ketogenic diet. The present review suggests treatment approaches for RSE based on subgroups, including CSE, NCSE, and NORSE. A discussion of recent clinical studies on AEDs and anesthetics in the management of RSE, as well as proposed treatment methods for NORSE, is also provided.

Treatment Guideline Nonadherence Pretransport Associated With Need for Higher Level of Care in Children Transferred to a Pediatric Tertiary Care Center for Status Epilepticus.

We sought to investigate the association between adherence to the American Epilepsy Society (AES) 2016 guidelines for management of convulsive status epilepticus (SE) and clinical outcomes among children requiring interhospital transport for SE. We hypothesized that pretransport guideline nonadherence would be associated with needing higher level of care posttransfer. This was a retrospective cohort study of children aged 30 days to 18 years transferred to our pediatric tertiary center from 2017 to 2019 for management of SE. Their care episodes were classified as 2016 American Epilepsy Society guideline adherent or nonadherent. There were 40 referring hospitals represented in this cohort. Of 260 care episodes, 55 (21%) were guideline adherent, 184 (71%) were guideline nonadherent, and 21 (8%) had insufficient data to determine guideline adherence. Compared with the adherent group, patients in the nonadherent care group had longer hospitalizations (32 hours [17-68] vs 21 hours [7-48], P = 0.006), were more likely to require intensive care unit admission (47% vs 31%), and less likely to be discharged home from the emergency department (16% vs 35%; χ 2 test, P = 0.01). Intubation rates did not differ significantly between groups (25% vs 18%, P = 0.37). When we fit a multivariable model to adjust for confounding variables, guideline nonadherence was associated with need for higher level of care (odds ratio, 2.04; 95% confidence interval, 1.04-3.99). Treatment guideline adherence did not improve over the 3-year study period (2017: 22%, 2018: 19%, 2019: 29% [χ 2 test for differences between any 2 years, P = 0.295]). Guideline nonadherence pretransport was associated with longer hospitalizations and need for higher level of care among children transferred for SE at our institution. These findings suggest a need to improve SE guideline adherence through multifaceted quality improvement efforts targeting both the prehospital and community hospital settings.

Comparison of levetiracetam as second-line drug with fosphenytoin in convulsive status epilepticus among children

Background: Status epilepticus (SE) is the most common neurologic emergency in the pediatric age group often serious and life-threatening. Although newer drugs were used, morbidity and mortality are still high. This study was done to compare the efficacy of levetiracetam with the existing second-line drug fosphenytoin in the treatment of SE. Subjects and Methods: This was a prospective, randomized parallel group trial from Pediatric Intensive Care Unit of a Tertiary Care Institute. One hundred children were recruited according to the inclusion and exclusion criteria, 50 in fosphenytoin group and 50 in levetiracetam group. Two groups were compared with respect to clinical cessation of seizures, recurrence, adverse event, and outcome. Results: Male-to-female ratio was 1.45:1. Seizure were controlled in 37 (74%) in fosphenytoin group and 28 (56%) in levetiracetam group) (P = 0.059). The mean time for cessation of seizures was 11.16 ± 3.58 min in fosphenytoin group as compared to was 12.78 ± 3.07 min in levetiracetam group (P = 0.059) The seizure recurrence in first 24 h (18 [36%] vs. 12 [24%]) (P = 0.643) and development of shock (14 [28%] vs. 11 [22%]) (P = 0.488) was comparable in two groups. Overall mortality was 10 (20%) in fosphenytoin group as compared to 7 (14%) levetiracetam group (P = 0.281). Conclusions: Efficacy of intravenous levetiracetam is comparable to fosphenytoin as a second-line medication in the management of convulsive SE in children.

Survey About Second-Line Agents for Pediatric Convulsive Status Epilepticus.

Convulsive status epilepticus (CSE) is the most common neurological emergency in children. It is a frequent cause of admission to pediatric intensive care units and is associated with significant short- and long-term morbidity. Management of CSE is a step-wise approach: first-line antiseizure agents (typically benzodiazepines) followed by a second-line agent before deeper anesthesia usually accompanied by intubation and ventilation. Current guidelines in the United Kingdom specify phenytoin as the second-line agent of choice for CSE. Two recent large international randomized controlled trials compared the efficacy of phenytoin with that of another second-line agent levetiracetam. Both studies found levetiracetam to be noninferior to phenytoin. We conducted an online survey of clinicians across 67 emergency departments that treat children and 29 pediatric intensive care units in the United Kingdom and Ireland to assess their current and preferred second-line agents for treating pediatric CSE in light of recently published evidence. The survey was distributed via the Pediatric Emergency Research in United Kingdom and Ireland network and the Pediatric Critical Care Society. We found that although most clinicians use phenytoin, as per current guidelines, they seek greater flexibility in choice of second-line agent, with levetiracetam being the preferred alternative to phenytoin. To facilitate use of levetiracetam for treatment of CSE in pediatrics, it should be included as a second-line agent in addition to phenytoin in the next update of the National Institute for Health and Care Excellence and other United Kingdom clinical guidelines.

Convulsive status epilepticus in children in Mozambique: Is there a treatment gap?

Background: Optimal care of Convulsive status epilepticus (CSE) can be related to multiple barriers in resource-limited countries.
 Objectives and methods: Since limited data of CSE management are available from South-East Africa, we performed a retrospective analysis of the electronic records of pediatric patients with CSE admitted to the Maputo Central hospital from January 2016 until April 2019.
 Results: Our database consisted out of 39 patients. The average age was 5.15 (range 0.3-13.8) years and demographic characteristics did not show a relation to CSE characteristics or outcomes. However, the total stay in the hospital was negatively correlated with age (p=0.0314). Moreover, 14 patients needed to be admitted to the IC, which was correlated to having generalized motor seizures (p=0.0253), and a relatively higher need for a second AED to control their CSE (p=0.0131). Regarding AED use, the first AED was a IV benzodiazepine (BZD: midazolam (MIDA) or diazepam (DIAZ)) or IV phenytoin (PHEN) when BZDs were not available. There was no statistically significant difference between the efficacy of MIDA vs. DIAZ. Eleven patients received PHEN as a second-line drug, of which only two patients needed an additional dose of PHEN. None of the patients died and five patients (13.2%) had an extra comorbidity after CSE.
 Conclusions: Although limited AEDs were available in our study, compared to more AEDs in other developing and developed countries, we report the successful cessation of CSE in the majority of cases. We recommend strategies to improve prehospital management such as the use of non-IV BZD use, to limit the need for patients to be admitted to the IC and thereby potentially decreasing the number of AEDs, morbidity and hospital duration. Moreover, our data underline the conversion to second-line AEDs (PHEN) to be adequate in nearly all patients.

Emergency management of the paediatric patient with convulsive status epilepticus.

This guideline addresses the emergency management of convulsive status epilepticus (CSE) in children and infants older than 1 month of age. It replaces a previous position statement from 2011, and includes a new treatment algorithm and table of recommended medications based on new evidence and reflecting the evolution of clinical practice over the past several years. This statement emphasizes the importance of timely pharmacological management of CSE, and includes some guidance for diagnostic approach and supportive care.

Acute Provoked Seizures-Work-Up and Management in Adults.

Acute provoked seizures, also known as acute symptomatic seizures, occur secondary to a neurological or systemic precipitant, commonly presenting as a first-time seizure. In this article, we will discuss etiology, emergent protocols, medical work-up, initial treatment, and management of these seizures. The definitions, classifications, and management of convulsive status epilepticus and nonconvulsive status epilepticus in an acute setting will also be reviewed.

Lorazepam timing for acute convulsive seizure control (LoTASC)

IntroductionGuidelines specify early administration of benzodiazepines (BZD) for the management of convulsive status epilepticus. The distinction between acute convulsive seizure and status epilepticus can be misconstrued resulting in BZD administration prior to a patient meeting criteria of status epilepticus. Early BZD administration may theoretically lead to systemic vital instability. Our study aims to assess if administering lorazepam, for convulsive seizures <5 min, causes vital instability. MethodsThis is a retrospective study analyzing patients who presented with a seizure lasting <5 min between 2011 and 2016. Continuous variables of lorazepam receivers versus non- receivers were analyzed using t-test for parametric and Mann-Whitney U test for nonparametric data. Categorical variables were analyzed using Chi-Square Test. Subsequently, subjects were analyzed through univariate and multivariate regression models to determine predictors of vital instability. ResultsOut of 1052 subjects initially screened, 165 were included. Of these, 91 (55 %) received lorazepam, and 74 (45 %) did not. Through univariate and multivariate analyses, there was a significantly higher incidence of vital instability (defined as receipt of a vasopressor or intubation) in patients who received lorazepam (OR = 6.76, 95 % CI = 1.48, 30.95) (p = 0.014). This was dose-dependent (p < 0.0001). It was responsible for 22.5 % of the vital instability. Lorazepam administration significantly prolonged the intensive care unit (ICU) length of stay (0 days [IQR 0 – 0] vs [IQR 0–2.3]; p = 0.038). ConclusionOur study suggests that lorazepam administration for acute convulsive seizures not meeting convulsive status epilepticus criteria may lead to iatrogenic vital instability and need for ICU admission.

Feasibility of phenytoin as a paramedic-led second-line anti-epileptic drug

Background: Convulsive status epilepticus (CSE) is a medical emergency that is commonly encountered in the prehospital setting. In almost all prehospital settings, treatment is limited to benzodiazepines even though the standard of care in emergency departments includes second-line agents such as phenytoin. Methods: A literature search was conducted using PubMed and Google Scholar using the search terms ‘phenytoin’, ‘seizure’ or ‘convulsive’ and ‘prehospital’, ‘EMS’ or ‘ambulance’ or ‘emergency department’. Five articles were analysed and a narrative review formed. Results: Phenytoin is an effective and commonly used second-line anti-epileptic agent but there is a distinct lack of evidence on prehospital phenytoin. Phasing the introduction of phenytoin into practice while simultaneously running a well-designed research trial could provide data for prehospital providers and the wider health community. Conclusion: Management of CSE will continue to present challenges to prehospital providers. Promoting the introduction of phenytoin to select patients, administered by advanced clinicians, could be an excellent opportunity to generate much-needed clinical data and potentially reduce morbidity and mortality in CSE.

Let’s discuss how to use the guideline for the evaluation and management of convulsive status epilepticus in children 2017

Let’s discuss how to use the guideline for the evaluation and management of convulsive status epilepticus in children 2017

Protocol-Driven Management of Convulsive Status Epilepticus at a Tertiary Children's Hospital: A Quality Improvement Initiative.

Convulsive status epilepticus is a medical emergency. Prompt treatment has been shown to decrease progression to refractory convulsive status epilepticus. We aimed to reduce time to second-line anti-seizure medication through implementation of a standardized treatment protocol. Quality improvement project. We constructed a multidisciplinary team and completed Plan-Do-Study-Act cycles to achieve the project aim. A tertiary care children's hospital. Patients presenting to the Children's Hospital at Montefiore emergency department with convulsive status epilepticus or new-onset seizures during admission to Children's Hospital at Montefiore. Implementation of a standardized treatment protocol, uploading the protocol to the hospital's intranet, adding anti-seizure medications to the hospital's Pyxis system, and creating a standardized convulsive status epilepticus order set in the electronic medical record. The primary outcome measure was time from order to administration of second-line anti-seizure medication, and secondary outcome was total seizure time. Seventy-eight patients were analyzed, including 41 from the baseline period (January 2014 through June 2015) and 37 from the postintervention period (July 2015 through December 2016). The median time to administration of second-line anti-seizure medication decreased from 52 to 21 minutes (p = 0.001) and total seizure time from 65 to 31 minutes (p = 0.09). A standardized treatment protocol for convulsive status epilepticus decreased time to administration of second-line therapy by 60%, but there was no statistically significant decrease in total seizure time.

Treatment gap for convulsive status epilepticus in resource-poor countries.

The magnitude of the treatment gap (TG) for convulsive status epilepticus (CSE) in resource-poor countries is unknown. Hospital-based cohort studies from developing countries revealed that the management of CSE was usually suboptimal due to lack of advanced diagnostic and treatment facilities, significant delay in patient's presentation at hospital, and shortages of essential antiepileptic drugs (AEDs). However, there were no significant differences in the proportion of refractory status epilepticus, short-term mortalities, and morbidities of CSE between the developed and the developing countries. Therefore, the presence of significant TG for CSE in developing countries is still an assumption without evidence. We conducted an expert survey in Asia for potential sources of TG. Experts from 16 Asian countries responded to the questionnaire. An injectable form of diazepam was available in all 16 countries even at the primary care level, but intravenous lorazepam was available only in four countries. Second-line AEDs were widely available at tertiary care hospitals, but not at primary care hospitals. Lack of second-line AEDs at primary care hospitals, significant delay in patient transportation to the hospital, shortages of intensive care unit facilities, and absence of trained physicians were important contributing factors to TG in Asia.

Cardiac Arrest in Patients Managed for Convulsive Status Epilepticus: Characteristics, Predictors, and Outcome.

Cardiac arrest is a catastrophic event that may arise during the management of convulsive status epilepticus. We aimed to report the clinical characteristics, outcomes, and early predictors of convulsive status epilepticus-related cardiac arrest. Retrospective multicenter study. Seventeen university or university affiliated participating ICUs in France and Belgium. Consecutive patients admitted to the participating ICUs for management of successfully resuscitated out-of-hospital cardiac arrest complicating the initial management of convulsive status epilepticus between 2000 and 2015. Patients were compared with controls without cardiac arrest identified in a single-center registry of convulsive status epilepticus patients, regarding characteristics, management, and outcome. None. We included 49 cases with convulsive status epilepticus-cardiac arrest and 235 controls. In the cases, median time from medical team arrival to cardiac arrest was 25 minutes (interquartile range, 5-85 min). First recorded rhythm was asystole in 25 patients (51%) and pulseless electrical activity in 13 patients (27%). A significantly larger proportion of patients had a favorable 1-year outcome (Glasgow Outcome Scale score of 5) among controls (90/235; 38%) than among cases (10/49; 21%; p = 0.02). By multivariate analysis, independent predictors of cardiac arrest were pulse oximetry less than 97% on scene (odds ratio, 2.66; 95% CI, 1.03-7.26; p = 0.04), drug poisoning as the cause of convulsive status epilepticus (odds ratio, 4.13; 95% CI, 1.27-13.53; p = 0.02), and complications during early management (odds ratio, 11.98; 95% CI, 4.67-34.69; p < 0.0001). Having at least one comorbidity among cardiac, respiratory, and neurologic (other than epilepsy) conditions predicted absence of cardiac arrest (odds ratio, 0.28; 95% CI, 0.10-0.80; p = 0.02). In patients managed for convulsive status epilepticus, relative hypoxemia, on-scene management complications, and drug poisoning as the cause of convulsive status epilepticus were strong early predictors of cardiac arrest, suggesting areas for improvement.

Convulsive status epilepticus management in adults and children: Report of the Working Group of the Polish Society of Epileptology

IntroductionThe Working Group was established at the initiative of the General Board of the Polish Society of Epileptology (PSE) to develop an expert position on the treatment of convulsive status epilepticus (SE) in adults and children in Poland. Generalized convulsive SE is the most common form and also represents the greatest threat to life, highlighting the importance of the choice of appropriate therapeutic treatment. Aim of guidelineWe present the therapeutic options separately for treatment during the early preclinical (>5–30min), established (30–60min), and refractory (>60min) SE phases. This division is based on time and response to AEDs, and indicates a practical approach based on pathophysiological data. ResultsBenzodiazepines (BZD) are the first-line drugs. In cases of ineffective first-line treatment and persistence of the seizure, the use of second-line treatment: phenytoin, valproic acid or phenobarbital is required. SE that persists after the administration of benzodiazepines and phenytoin or another second-line AED at appropriate doses is defined as refractory and drug resistant and requires treatment in the intensive care unit (ICU). EEG monitoring is essential during therapy at this stage. Anesthesia is typically continued for an initial period of 24h followed by a slow reversal and is re-established if seizures recur. Anesthesia is usually administered either to the level of the “burst suppression pattern” or to obtain the “EEG suppression” pattern. ConclusionsExperts agree that close and early cooperation with a neurologist and anesthetist aiming to reduce the risk of pharmacoresistant cases is an extremely important factor in the treatment of patients with SE. This report has educational, practical and organizational aspects, outlining a standard plan for SE management in Poland that will improve therapeutic efficacy.

Randomized controlled trial of levetiracetam versus fosphenytoin for convulsive status epilepticus in children

Introduction: Convulsive status epilepticus (CSE) is a common neurological emergency in childhood carrying a risk of significant morbidity and mortality. The current recommended first choice second line treatment in children is phenytoin / fosphenytoin although there is lack of evidence for its use and it is associated with significant side effects. Emerging evidence suggest that intravenous (IV) levetiracetam may be more effective with fewer side effects. The objective of this study was to compare the efficacy and safety of IV levetiracetam as a second line treatment for CSE with IV fosphenytoin in Indian children. Methods: Design: Prospective randomized controlled trial. Study setting: Paediatric emergency department of a Medical College in Tamilnadu, India from January 2017 to June 2017. Study population: 50 children aged 3 months to 12 years admitted for CSE and in whom seizure has failed to terminate with 2 doses of benzodiazepine. Intervention: 20mg Phenytoin equivalent (PE)/kg of fosphenytoin or 30mg/kg of levetiracetam administered intravenously over 7 minutes. Primary outcome: clinical cessation of seizures five minutes following the completion of the infusion of the study medication. Secondary outcome: seizure recurrence within 24 hours, drug related adverse events and length of PICU and hospital stay. Results: Fosphenytoin terminated seizures earlier than levitiracetam (p= 0.029). There was no significant difference between the two drugs in other parameters including seizure control rate (p=0.667), seizure recurrence (p=0.44), seizure free duration (p=0.8), PICU stay (p=0.105) and hospital stay (p=0.311). Conclusion: Levetiracetam may be an effective alternative to fosphenytoin in the management of convulsive status epilepticus in children.

Management of convulsive status epilepticus in children: an adapted clinical practice guideline for pediatricians in Saudi Arabia.

Objective:To increase the use of evidence-based approaches in the diagnosis, investigations and treatment of Convulsive Status Epilepticus (CSE) in children in relevant care settings.Method:A Clinical Practice Guideline (CPG) adaptation group was formulated at a university hospital in Riyadh. The group utilized 2 CPG validated tools including the ADAPTE method and the AGREE II instrument.Results:The group adapted 3 main categories of recommendations from one Source CPG. The recommendations cover; (i)first-line treatment of CSE in the community; (ii)treatment of CSE in the hospital; and (iii)refractory CSE. Implementation tools were built to enhance knowledge translation of these recommendations including a clinical algorithm, audit criteria, and a computerized provider order entry.Conclusion:A clinical practice guideline for the Saudi healthcare context was formulated using a guideline adaptation process to support relevant clinicians managing CSE in children.

Optimizing the Diagnosis and Management of Dravet Syndrome: Recommendations From a North American Consensus Panel

ObjectivesTo establish standards for early, cost-effective, and accurate diagnosis; optimal therapies for seizures; and recommendations for evaluation and management of comorbidities for children and adults with Dravet syndrome, using a modified Delphi process. MethodsAn expert panel was convened comprising epileptologists with nationally recognized expertise in Dravet syndrome and parents of children with Dravet syndrome, whose experience and understanding was enhanced by their active roles in Dravet syndrome associations. Panelists were asked to base their responses to questions both on their clinical expertise and results of a literature review that was forwarded to each panelist. Three rounds of online questionnaires were conducted to identify areas of consensus and strength of that consensus, as well as areas of contention. ResultsThe panel consisted of 13 physicians and five family members. Strong consensus was reached regarding typical clinical presentation of Dravet syndrome, range of electroencephalography and magnetic resonance imaging findings, need for genetic testing, critical information that should be conveyed to families at diagnosis, priorities for seizure control and typical degree of control, seizure triggers and recommendations for avoidance, first- and second-line therapies for seizures, requirement and indications for rescue therapy, specific recommendations for comorbidity screening, and need for family support. Consensus was not as strong regarding later therapies, including vagus nerve stimulation and callosotomy, and for specific therapies of associated comorbidities. Beyond the initial treatment with benzodiazepines and use of valproate, there was no consensus on the optimal in-hospital management of convulsive status epilepticus. ConclusionsWe were able to identify areas where there was strong consensus that we hope will (1) inform health care providers on optimal diagnosis and management of patients with Dravet syndrome, (2) support reimbursement from insurance companies for genetic testing and Dravet syndrome–specific therapies, and (3) improve quality of life for patients with Dravet syndrome and their families by avoidance of unnecessary testing and provision of an early accurate diagnosis allowing optimal selection of therapeutic strategies.

Lorazepam or diazepam for convulsive status epilepticus: A meta-analysis

Convulsive status epilepticus (CSE) is a neurological emergency in adults and children. However, whether a particular benzodiazepine is of superior efficacy and safety in management of CSE is controversial. We performed a meta-analysis to compare the outcome of lorazepam and diazepam for treating CSE. We searched the PubMed, Medline, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar databases from 1966 to February 2014. No language restriction was applied. Reference lists of all the selected articles were hand-searched for any additional trials. Trial quality was assessed using the modified Jadad scale and the Consolidated Standards Of Reporting Trials (CONSORT) checklist. Two authors independently extracted data from all eligible studies, including study design, participants, interventions, and outcomes. The data was analyzed using fixed-effects or random-effects models with mean differences and risk ratios for continuous and dichotomous variables, respectively. A total of six studies involving 970 patients were included in this analysis. The majority of patients were children (n=574) and 396 patients were adults. Meta-analysis showed no significant difference between the two treatment groups regarding seizure control and adverse effects regardless of patient age. This meta-analysis demonstrates that diazepam and lorazepam have equal efficacy and side effects for treating CSE in adults and children, and either can be chosen as a reasonable first-line therapy. More high quality randomized controlled trials are needed to support this finding.